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Giannakis P, Zhuang ST, Rosenstadt JL, Marx RG. One-stage revision anterior cruciate ligament reconstruction: Preoperative evaluation, planning and surgical techniques. A review of current concepts. J Exp Orthop 2025; 12:e70111. [PMID: 39816950 PMCID: PMC11733443 DOI: 10.1002/jeo2.70111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2024] [Revised: 10/18/2024] [Accepted: 10/24/2024] [Indexed: 01/18/2025] Open
Abstract
The increased rate of anterior cruciate ligament (ACL) tears has led to a greater number of revisions. Revision surgery can be performed in one or two stages. Single-stage revision ACL reconstruction (ssRACLR) may be performed when prior tunnels can be re-used or bypassed whereas a two-stage procedure is indicated when bone grafting of dilated tunnels prior to revision is necessary. While both approaches have shown similar functional outcomes and failure risk, ssRACLR is preferred, when possible, to avoid the increased morbidity, inconvenience and cost associated with two-stage RACLR. In adequately planning for RACLR, a surgeon should investigate the mechanism and timing of injury as well as the previous graft selection, associated pathology and the tunnel placement and size. It is especially important to obtain radiographs and three-dimensional imaging including magnetic resonance imaging (MRI) and computed tomography (CT), which allow the surgeon to accurately evaluate the entire tunnel architecture to determine surgical staging. Following a detailed assessment of the pathoanatomy, the surgeon may determine graft and hardware type, tunnel placement and utilization of lateral extra-articular tenodesis (LET) and other procedures. In our experience, ssRACLR can be carried out for over 90% of revision cases with creative pre-operative planning using autograft with bone plug(s), divergent tunnel creation on the femur (when necessary) and convergent tunnel creation on the tibia (when appropriate) and suspensory or interference fixation as needed. In revision scenarios, we believe that autografts with bone plugs provide the best opportunity for graft healing and incorporation and that LET can be a useful adjunct to reduce re-tear rates. The purpose of this review is to report on the preoperative considerations and surgical techniques for performing ssRACLR, as well as the outcomes. Level of Evidence Level V expert opinion.
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Affiliation(s)
- Periklis Giannakis
- Department of Sports MedicineHospital for Special SurgeryNew YorkNew YorkUSA
- Department of AnesthesiologyCritical Care & Pain ManagementNew YorkNew YorkUSA
| | - Sophia T. Zhuang
- Department of Sports MedicineHospital for Special SurgeryNew YorkNew YorkUSA
| | - Jacob L. Rosenstadt
- Department of Sports MedicineHospital for Special SurgeryNew YorkNew YorkUSA
- Georgetown University School of MedicineWashington, DCUSA
| | - Robert G. Marx
- Department of Sports MedicineHospital for Special SurgeryNew YorkNew YorkUSA
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Ricchi T, Di Muro A, Taha ZA, Franco P, Matassi F. Anterior Cruciate Ligament Revision Using Bone-Patellar Tendon-Bone Autograft and Lateral Extra-articular Tenodesis. Arthrosc Tech 2024; 13:103149. [PMID: 39780896 PMCID: PMC11704902 DOI: 10.1016/j.eats.2024.103149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2024] [Accepted: 06/01/2024] [Indexed: 01/11/2025] Open
Abstract
Revision of anterior cruciate ligament reconstruction presents various challenges not encountered in the primary settings, including malpositioned tunnels, tunnel widening, and the lack of consensus on the ideal graft to be used. This Technical Note describes a one-stage anterior cruciate ligament reconstruction revision using a bone-patellar tendon-bone autograft combined with lateral extra-articular tenodesis. This technique represents the ideal approach to tackle complex revision cases primarily characterized by tibial and femoral tunnel osteolysis and rotational knee instability. The bone-patellar tendon-bone autograft offers numerous advantages mainly providing a double bone plug, which is critical when encountering cases with tibial and femoral tunnel widening. In addition, a lateral extra-articular tenodesis alongside the revision enhances rotational knee stability reducing stress on the graft and ensuring better graft survival.
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Affiliation(s)
- Tommaso Ricchi
- Department of Orthopaedics, University Hospital of Florence - A.O.U. Careggi, Florence, Italy
| | - Andrea Di Muro
- Department of Orthopaedics, University Hospital of Florence - A.O.U. Careggi, Florence, Italy
| | - Zyad Ayman Taha
- Department of Orthopaedics, University Hospital of Florence - A.O.U. Careggi, Florence, Italy
| | - Piero Franco
- Department of Orthopaedics, University Hospital of Florence - A.O.U. Careggi, Florence, Italy
| | - Fabrizio Matassi
- Department of Orthopaedics, University Hospital of Florence - A.O.U. Careggi, Florence, Italy
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Patil B, Goyal S, Salwan A, Singh R. Anterior Cruciate Ligament Reconstruction in Young Athletes: A Comprehensive Review of Lateral Extra-Articular Tenodesis and Anterolateral Ligament Reconstruction Techniques. Cureus 2024; 16:e70333. [PMID: 39469369 PMCID: PMC11513215 DOI: 10.7759/cureus.70333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2024] [Accepted: 09/24/2024] [Indexed: 10/30/2024] Open
Abstract
Anterior cruciate ligament (ACL) injuries are prevalent among young athletes and pose significant challenges due to their impact on immediate and long-term knee function. Traditional ACL reconstruction techniques, while effective, may not always meet the unique needs of this population, particularly given their high physical demands and the risk of future complications. This review evaluates two advanced surgical techniques - lateral extra-articular tenodesis (LEAT) and anterolateral ligament (ALL) reconstruction - as potential enhancements to conventional ACL reconstruction. LEAT involves augmenting knee stability by addressing lateral compartment issues, while ALL reconstruction focuses on reconstructing the ALL to improve overall knee function. The review compares these techniques regarding surgical procedures, clinical outcomes, biomechanical effectiveness, and complications. LEAT and ALL reconstruction are examined for their impact on recovery, return-to-sport rates, and long-term knee health, highlighting their advantages and limitations. Findings suggest that both techniques offer promising benefits, with the potential for improved outcomes compared to traditional methods. However, the effectiveness of each technique can vary based on individual factors and the specific demands of different sports. Further research is needed to fully understand the long-term implications and refine these approaches. This review aims to guide clinical decision-making and optimize treatment strategies for young athletes with ACL injuries, enhancing their prospects for a successful return to athletic activity.
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Affiliation(s)
- Bhushan Patil
- Orthopaedics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Saksham Goyal
- Orthopaedics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Ankur Salwan
- Orthopaedics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Rahul Singh
- Orthopaedics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Chirico M, Taha ZA, Carminati M, Civinini R, Matassi F. Complex Anterior Cruciate Ligament Revision and Lateral Extra-Articular Tenodesis With Achilles Tendon Allograft: The "Monoloop" Technique. Arthrosc Tech 2024; 13:102826. [PMID: 39036402 PMCID: PMC11258670 DOI: 10.1016/j.eats.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 09/03/2023] [Indexed: 07/23/2024] Open
Abstract
Revision of anterior cruciate ligament reconstruction (ACL-R) presents many challenges that are not encountered in the primary setting and, therefore, requires thorough preoperative planning. Recently, there has been growing evidence showing that combining the anterolateral ligament (ALL) reconstruction with ACL-R revision reduces the risk of postoperative ACL rupture and meniscal tears, and therefore, the ALL reconstruction becomes essential to a complex ACL revision. The technique that we describe is mainly used in the setting of complex ACL revision with extensive tunnel osteolysis associated with rotational instability of the knee. This article presents a technique for a one-stage complex ACL-R revision combined with ALL reconstruction using an Achilles tendon allograft with a bone plug.
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Affiliation(s)
- Mattia Chirico
- University of Florence, Orthopaedic Clinic CTO, Careggi, Florence, Italy
| | - Zyad Ayman Taha
- University of Florence, Orthopaedic Clinic CTO, Careggi, Florence, Italy
| | - Mattia Carminati
- University of Florence, Orthopaedic Clinic CTO, Careggi, Florence, Italy
| | - Roberto Civinini
- University of Florence, Orthopaedic Clinic CTO, Careggi, Florence, Italy
| | - Fabrizio Matassi
- University of Florence, Orthopaedic Clinic CTO, Careggi, Florence, Italy
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Borim FM, Jubert NJ, Vinaixa MMR, Portas-Torres I, Bueno JP, Mayayo RS, Peiró JVA, Feliu EC, Monyart JM. Good rates of return-to-sport in athletes after revision anterior cruciate ligament reconstruction using autologous patellar tendon and lateral extra-articular tenodesis: a 2-year follow-up prospective study. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:3125-3133. [PMID: 37039899 PMCID: PMC10504162 DOI: 10.1007/s00590-023-03544-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 04/03/2023] [Indexed: 04/12/2023]
Abstract
BACKGROUND Most athletes who undergo revision of the anterior cruciate ligament reconstruction (ACLR) aim to return to their preinjury sport at a similar level of performance while minimizing the risk for reinjury. Additional lateral extra-articular tenodesis (LET) has recently been correlated with improved outcomes and low complication rate. Yet, there are few series evaluating return-to-sport (RTS) and clinical outcomes after revision ACLR using bone-patellar tendon-bone (BPTB) and LET in athletes. METHODS The study cohort consisted of 19 eligible athletes who had undergone their first revision ACLR using BPTB and LET (modified Lemaire) between January 2019 and 2020. Patients were prospectively followed and interviewed in a sports activity survey during a 2-year follow-up. RESULTS Despite all patients returning to sports after revision ACLR surgery, 52.6% resumed playing at their preinjury level. Furthermore, patient-reported functional outcomes improved significantly following revision surgery, as evidenced by improvements in IKDC [64.4 (± 12) to 87.8 (± 6)], Lysholm [71.27 (± 12) to 84.2 (± 9.7)], and SF-12 scales [Physical: 53.3 (± 3) 57 (± 1.2); Mental: 50.2 (± 3.3) to 52.7 (± 2.4)]. One case (5.3%) experienced persistent pain and underwent reoperation for a partial meniscectomy. CONCLUSION After revision ACLR using autologous BPTB and LET, all active individuals are expected to RTS, similar to primary ACLR. The difference comes down to returning to the preinjury level, where the levels are lower depending on the sport and initial level of play. Good mid-term functional outcomes with a low complication rate can be expected in most cases. STUDY DESIGN Case series; Level of evidence IV. ETHICAL COMMITTEE APPROVAL NUMBER PR(ATR)79/2021 and HCB/2023/0173.
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Affiliation(s)
- Felipe Moreira Borim
- Surgery and Morphological Sciences, Universitat Autónoma de Barcelona (UAB), 08193, Bellaterra, Barcelona, Spain.
- Orthopaedic Surgery Department; Knee Surgery Unit, Hospital Universitari Vall d'Hebron, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain.
- Bioengineering, Cell Therapy and Surgery in Congenital Malformations - VHIR, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129, 08035, Barcelona, Spain.
| | - Nayana Joshi Jubert
- Surgery and Morphological Sciences, Universitat Autónoma de Barcelona (UAB), 08193, Bellaterra, Barcelona, Spain
- Orthopaedic Surgery Department; Knee Surgery Unit, Hospital Universitari Vall d'Hebron, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Reconstructive Surgery of Locomotor System Group - VHIR, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - Maria Mercedes Revertè Vinaixa
- Surgery and Morphological Sciences, Universitat Autónoma de Barcelona (UAB), 08193, Bellaterra, Barcelona, Spain
- Orthopaedic Surgery Department; Knee Surgery Unit, Hospital Universitari Vall d'Hebron, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Reconstructive Surgery of Locomotor System Group - VHIR, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Knee Surgery Unit, Clínica Corachan, Carrer de Buïgas, 19, 08017, Barcelona, Spain
| | - Irene Portas-Torres
- Orthopaedic Surgery Department; Knee Surgery Unit, Hospital Universitari Vall d'Hebron, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - Joan Pijoan Bueno
- Surgery and Morphological Sciences, Universitat Autónoma de Barcelona (UAB), 08193, Bellaterra, Barcelona, Spain
- Orthopaedic Surgery Department; Knee Surgery Unit, Hospital Universitari Vall d'Hebron, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Reconstructive Surgery of Locomotor System Group - VHIR, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Knee Surgery Unit, Clínica Corachan, Carrer de Buïgas, 19, 08017, Barcelona, Spain
| | - Raquel Sevil Mayayo
- Orthopaedic Surgery Department; Knee Surgery Unit, Hospital Universitari Vall d'Hebron, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Knee Surgery Unit, Clínica Corachan, Carrer de Buïgas, 19, 08017, Barcelona, Spain
| | - José Vicente Andrés Peiró
- Surgery and Morphological Sciences, Universitat Autónoma de Barcelona (UAB), 08193, Bellaterra, Barcelona, Spain
- Reconstructive Surgery of Locomotor System Group - VHIR, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Knee Surgery Unit, Clínica Corachan, Carrer de Buïgas, 19, 08017, Barcelona, Spain
| | - Enric Castellet Feliu
- Surgery and Morphological Sciences, Universitat Autónoma de Barcelona (UAB), 08193, Bellaterra, Barcelona, Spain
- Orthopaedic Surgery Department; Knee Surgery Unit, Hospital Universitari Vall d'Hebron, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Reconstructive Surgery of Locomotor System Group - VHIR, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - Joan Minguell Monyart
- Surgery and Morphological Sciences, Universitat Autónoma de Barcelona (UAB), 08193, Bellaterra, Barcelona, Spain.
- Orthopaedic Surgery Department; Knee Surgery Unit, Hospital Universitari Vall d'Hebron, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain.
- Reconstructive Surgery of Locomotor System Group - VHIR, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129, 08035, Barcelona, Spain.
- Knee Surgery Unit, Clínica Corachan, Carrer de Buïgas, 19, 08017, Barcelona, Spain.
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Abstract
Anterior cruciate ligament (ACL) graft failure from rupture, attenuation, or malposition may cause recurrent subjective instability and objective laxity, and occurs in 3% to 22% of ACL reconstruction (ACLr) procedures. Revision ACLr is often indicated to restore knee stability, improve knee function, and facilitate return to cutting and pivoting activities. Prior to reconstruction, a thorough clinical and diagnostic evaluation is required to identify factors that may have predisposed an individual to recurrent ACL injury, appreciate concurrent intra-articular pathology, and select the optimal graft for revision reconstruction. Single-stage revision can be successful, although a staged approach may be used when optimal tunnel placement is not possible due to the position and/or widening of previous tunnels. Revision ACLr often involves concomitant procedures such as meniscal/chondral treatment, lateral extra-articular augmentation, and/or osteotomy. Although revision ACLr reliably restores knee stability and function, clinical outcomes and reoperation rates are worse than for primary ACLr.
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Affiliation(s)
- Paul M Inclan
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Robert H Brophy
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
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